Sexually Transmitted Infection (STI) Risks in Same-Sex Relationships

Sexually transmitted infections (STIs) pose a significant public health concern for all sexually active individuals, regardless of sexual orientation. However, certain populations within the LGBTQ+ community face unique risks and disparities in STI rates due to a complex interplay of behavioral, biological, and social factors. By way of this report, we want to discuss the specific STI risks faced by individuals in same-sex relationships, including gay, bisexual, and other men who have sex with men (MSM), lesbian and bisexual women (WSW), and transgender individuals.

STI Risks for Gay, Bisexual, and Other Men Who Have Sex with Men (MSM)

MSM are disproportionately affected by certain STIs, particularly HIV and syphilis. While anyone who has sex can acquire an STI, MSM have higher rates of syphilis and account for over half of all new HIV infections.

Key STI Risks for MSM:

• HIV: MSM remain the population most affected by HIV, with higher prevalence and incidence rates compared to other groups. Factors contributing to this include higher rates of HIV within the MSM community, certain sexual practices, and socio-structural issues.

• Syphilis: Rates of syphilis are significantly higher among MSM. This bacterial infection can cause serious health problems if left untreated.

• Gonorrhea and Chlamydia: While these bacterial infections can affect anyone, MSM are at increased risk for rectal and pharyngeal (throat) infections due to anal and oral sex practices. These infections are often asymptomatic, leading to delayed diagnosis and potential transmission.

• Hepatitis A and B: These viral infections can be transmitted sexually, particularly through oral-anal contact. Vaccination is recommended for MSM.

• Human Papillomavirus (HPV): HPV can cause genital warts and certain cancers (e.g., anal cancer, throat cancer). Anal HPV infection is common among MSM, and vaccination is recommended.

Factors Contributing to Higher STI Rates in MSM:

• Sexual Practices: Anal sex, both insertive ("top") and receptive ("bottom"), carries a higher risk for STI transmission due to the delicate nature of rectal tissues. Oral sex can also transmit certain STIs.

• Multiple Partners and Partner Networks: Having multiple sexual partners, especially anonymous or casual partners, increases the likelihood of exposure to STIs.

• Lack of Consistent Condom Use: Inconsistent or incorrect use of condoms remains a significant risk factor.

• Asymptomatic Infections: Many STIs are asymptomatic, meaning individuals may not know they are infected and can unknowingly transmit the infection to partners.

• Substance Use: Alcohol and recreational drug use can lower inhibitions, leading to engaging in risky sexual behaviors.

• Stigma, Discrimination, and Healthcare Access: Homophobia, stigma, and discrimination can negatively influence health-seeking behaviors, leading to delayed testing and treatment. Some MSM may also face barriers to accessing culturally competent healthcare.

STI Risks for Lesbian and Bisexual Women (WSW)

There is a common misconception that WSW are at low or no risk for STIs. However, WSW are susceptible to a range of STIs, and their risks are comparable to, and in some cases, even higher than, those of heterosexual women.

Key STI Risks for WSW:

• Human Papillomavirus (HPV): HPV can be transmitted through skin-to-skin contact, including vulva-to-vulva contact, and can cause genital warts and increase the risk of cervical, vaginal, and vulvar cancers. Regular Pap tests are crucial for all WSW.

• Herpes Simplex Virus (HSV): Genital herpes can be transmitted through skin-to-skin contact, even in the absence of visible sores.

• Bacterial Vaginosis (BV) and Trichomoniasis: These are common vaginal infections that can be transmitted between women through the exchange of vaginal fluids.

• Chlamydia and Gonorrhea: While less common than in MSM, these bacterial infections can be transmitted between women through shared sex toys, hands, and vulva-to-vulva rubbing, especially if there are cuts or tears.

• Syphilis and HIV: While less frequently reported, there have been documented cases of HIV and syphilis transmission between women, particularly during menstruation or through practices involving blood exchange (e.g., fisting, shared needles for piercing/S&M). Bisexual women who also have sex with men face the same STI risks as heterosexual women in addition to the risks associated with WSW practices.

Factors Contributing to STI Risks in WSW:

• Misconceptions and Lack of Awareness: The belief that WSW are not at risk for STIs can lead to a lack of testing, discussions about sexual health with partners, and safer sex practices.

• Sexual Practices: Direct skin-to-skin contact, exchange of vaginal fluids, and shared sex toys can facilitate STI transmission.

• Previous Male Partners: Many WSW have had sex with men in the past and may carry asymptomatic STIs from previous heterosexual encounters.

• Lack of Routine STI Screening: Healthcare providers may not routinely offer comprehensive STI screening to WSW due to incorrect assumptions about their risk.

STI Risks for Transgender Individuals

Transgender individuals, particularly transgender women (TGW), face unique and often elevated risks for STIs, including HIV. Their risk profile is influenced by a combination of biological factors, sexual behaviors, and significant social and structural determinants of health.

Key STI Risks for Transgender Individuals:

• Transgender Women (TGW): TGW who have sex with men often face similar STI risks as MSM, including higher rates of HIV, syphilis, gonorrhea, and chlamydia. Studies have shown a high prevalence of bacterial STIs in TGW, particularly those living with HIV.

• Transgender Men (TGM): TGM who have sex with men, women, or both face STI risks dependent on their sexual practices. TGM who have sex with men are at risk for STIs commonly seen in MSM. TGM who have sex with cisgender women may be at risk for STIs typically seen in heterosexual relationships.

• Hormone Therapy and Surgical Procedures: While hormone therapy and gender-affirming surgeries do not directly cause STIs, they can influence sexual health. For example, some hormone therapies can affect vaginal or anal tissue, potentially increasing susceptibility to certain infections.

Factors Contributing to STI Risks in Transgender Individuals:

• Discrimination and Stigma: Transphobia and discrimination in healthcare settings can lead to avoidance of medical care, delayed STI testing, and inadequate treatment.

• Socioeconomic Disparities: Transgender individuals often face higher rates of poverty, homelessness, and unemployment, which can be associated with increased STI risk due to limited access to healthcare, stable housing, and resources.

• Sexual Behavior: As with all individuals, sexual practices, number of partners, and condom use directly influence STI risk.

• Lack of Culturally Competent Care: Healthcare providers may lack knowledge and training on transgender health, leading to misgendering, uncomfortable experiences, and insufficient STI screening and prevention strategies.

Prevention and Management of STIs in Same-Sex Relationships

Effective STI prevention and management in same-sex relationships require a multifaceted approach that addresses individual behaviors, healthcare system accessibility, and societal factors.

Key Prevention Strategies:

• Regular STI Testing: Consistent and targeted STI screening is paramount.

  • MSM: Annual HIV and syphilis testing is recommended. Rectal chlamydia and gonorrhea screening for those engaging in receptive anal sex, and pharyngeal gonorrhea screening for those engaging in oral sex. Hepatitis B and C screening based on risk factors.

  • WSW: Regular Pap tests for cervical health are crucial. STI testing should be considered based on sexual history, symptoms, and partner risk factors.

  • Transgender Individuals: Screening should be tailored to individual sexual practices and anatomical sites of exposure.

• Safer Sex Practices:

  • Condom Use: Consistent and correct use of condoms (internal or external) for anal, vaginal, and oral sex significantly reduces STI transmission.

  • Dental Dams and Other Barriers: Using dental dams or plastic wrap during oral-vaginal or oral-anal contact can reduce skin-to-skin and fluid transmission.

  • Sex Toy Hygiene: Cleaning sex toys thoroughly between uses and between partners, or using a new condom for each use/partner, is essential.

  • Hand Hygiene: Washing hands before and after sexual activity, especially for digital-vaginal or digital-anal contact, can reduce transmission of certain infections.

• Vaccinations:

  • HPV Vaccine: Recommended for individuals up to age 26, and for some adults aged 27-45, to prevent HPV-related cancers and warts.

  • Hepatitis A and B Vaccines: Recommended for at-risk individuals, including MSM.

• Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP) for HIV: PrEP is a highly effective HIV prevention method for individuals at high risk. PEP can be used after potential HIV exposure to prevent infection.

• Open Communication with Partners: Discussing sexual health, STI status, and testing history with partners before engaging in sexual activity is vital.

• Reducing Number of Partners: Limiting the number of sexual partners can decrease the likelihood of STI exposure.

• Harm Reduction for Substance Use: Addressing alcohol and drug use that may lead to risky sexual behaviors.

Management and Treatment:

• Early Diagnosis and Treatment: Prompt diagnosis and treatment of STIs are crucial to prevent complications and further transmission.

• Partner Notification and Treatment: If diagnosed with an STI, notifying sexual partners so they can also get tested and treated is essential to break the chain of transmission. Expedited Partner Therapy (EPT) may be an option in some cases.

• Comprehensive Healthcare: Access to affirming and knowledgeable healthcare providers who understand the specific needs of same-sex couples and transgender individuals is paramount.

While sexual orientation does not inherently dictate STI risk, specific sexual practices and societal factors can contribute to disproportionate STI burdens in certain same-sex populations. Recognizing these unique risks is the first step toward promoting sexual health equity. By implementing targeted prevention strategies, increasing access to culturally competent healthcare, and fostering open communication, we can work towards reducing STI rates and improving the sexual well-being of all individuals in same-sex relationships.